Keywords

The intention of sleep assessment is to provide sufficient and accurate data to determine treatment. Accurate sleep assessment is the first step in effective sleep management by the physiotherapist. Information on the nature of sleep disturbance, physiologic, behavioral, and emotional aspects, as previous experiences with sleep, are crucial for the beginning of the treatment and also for managing treatment. Valid and reliable measurements of sleep are needed to identify patients who require intervention and to evaluate the effectiveness of an intervention.

A detailed anamnesis includes an assessment of numerous variables that may interfere with sleep and may play crucial roles in sleep management. Patient characteristics such as age, gender, ethnicity, profession, and marital status should never be missed in the assessment. It is interesting to have height, weight (to calculate body mass index, BMI), and measures of the neck and abdominal circumference. Listed below are samples of key questions regarding sleep-related issues and disorders:

  • Sleep routine: time of going to bed and waking up

  • Quality of sleep: nonrestorative or unrefreshing?

  • Difficulties falling asleep, staying awake during the night

  • Number of hours that sleep refreshes vs. number of hours that really sleeps

  • Adequate opportunity to sleep

  • Somnolence during the day: tendency to nap easily during the day?

  • How and when sleep disturbance/complaint started?

  • Fragmented seep? How many awakenings?

  • Tendency to snort or choke during sleep

  • Tendency to stop breathing during sleep

  • Witnessed apnea, lack of breathing or choking

  • Grind teeth during sleep?

  • Wake up during the night due to which reason?

  • In which position do you sleep?

  • Tendency to go to the bathroom/toilette during the night? How many times? Nocturia?

  • Do you move a lot during the night?

  • Environmental questions: How is your bedroom? Cozy? Warm? Blackout curtains? Loud disruptive snoring?

  • Medications (that can interfere within sleep)

  • History of appearing to “act out one’s dreams” such as punching or flailing arms in the air, shouting, or screaming

  • Tendency to experience unpleasant, nervous, creepy-crawly sensations in the legs/feet, primarily at night or when sitting at rest, an urge to move the legs, and the tendency for the unpleasant sensations to temporarily be relieved by moving the legs or walking

  • A propensity for the legs to periodically jerk during sleep

  • Propensity to experience cramps prior to or during sleep

  • Tendency to struggle falling asleep before 1 h and 3 h (AM), and then tendency to awaken after 8 h in the morning

  • Propensity to struggle to maintain wakefulness prior to 8 h in the evening, and then tendency to awaken earlier than 6 h in the morning

If in the anamnesis the physiotherapist suspects of any symptom or disease, questionnaires to evaluate them should be included, aiming to help within the clinical picture, as the diagnosis is performed by the sleep specialized physician and to monitor treatment.

Some scales are helpful for tracking a patient’s progress. Some sleep diseases might need objective examinations prescribed by the physician or need the video recording of the sleep (e.g., REM sleep behavior disorder or sleep bruxism) to get to a defined diagnosis. Depending on the questionnaire, it is translated, validated, and adapted into many languages, including Brazilian Portuguese, English, Portuguese, French, German, Italian, Japanese, Korean, Spanish, Thai, and Turkish. Please do check the status of available translations within the preferred language.

There are several questionnaires for sleep assessment, which are easy, costless, and very manageable at the physiotherapist clinic. Here we present questionnaires that have reliability and validity against objective measures and can be incorporated into physical therapists’ (PTs) anamnesis and treatment outcomes evaluation (Table 1). These are subjective measures that assess self-perception of quality and quantity of sleep and can assist in the diagnosis of sleep disorders. Just a reminder that the questionnaires are not designed to provide clinical diagnoses by themselves.

Table 1 Questionnaires used to assess sleep quality, sleepiness, insomnia, risk for apnea, narcolepsy, restless leg syndrome, pain, and circadian preference
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For the evaluation of general sleep, the Pittsburgh Sleep Quality Index (PSQI) [1] is one of the most used in research and clinical practice, assessing sleep quality in a 1-month interval. PSQI is an extensive questionnaire on the behavior of sleeping times and problems. In addition, there are the Jenkins Sleep Evaluation Questionnaire (JSEQ) [2] and the Sleep Scale from the Medical Outcomes Study (MOS-Sleep) [3], which are also well used.

In respect of disease-specific instruments, there are many designed to assess specific conditions of the disease itself. For the sleepiness evaluation, there are some assessment tools such as the Epworth Sleepiness Scale (ESS) [4] (Fig. 1), the Stanford Sleepiness Scale (SSS) [5], and the Karolinska Sleepiness Scale (KSS) [6], which help to assess the impact of sleepiness on the ability to conduct daily activities.

Fig. 1
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Epworth sleepiness scale. (Reprinted with permission from Johns. Publisher: Oxford University Press [4])

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For insomnia, the Insomnia Severity Index (ISI) [7](Fig. 2), the Athens Insomnia Scale [8], and the Insomnia Symptom Questionnaire (ISQ) [9] are among the most used questionnaires, designed to establish a clinically relevant case definition of insomnia consistent with widely used insomnia classification criteria.

Fig. 2
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Insomnia severity index. (Reprinted with permission from Bastien et al. Elsevier Science [7])

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Population-based studies evaluating the accuracy of screening questionnaires for OSA against PSG were Berlin questionnaire [11], STOP-Bang Questionnaire [10] (Fig. 3), and NoSAS Score [12]. Regarding OSA, mouth and jaw can also be analyzed by a visual inspection, using the modified Mallampati Classification, which visually classifies the amount of mouth opening to the size of the tongue, and provides an estimate of space available for oral intubation by direct laryngoscopy (Fig. 4). A high Mallampati score (class 3 or 4) is associated with a higher incidence of sleep apnea [21, 22]. It is important at this moment to evaluate the patency of the oropharynx, and to measure neck circumference, and also the development of the maxilla (hypoplasia) and mandible (mandibular retro position) because retrognathia is a risk factor and, when added to other elements, can worsen obstructive sleep apnea [23, 24].

Fig. 3
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STOP-Bang questionnaire . (Reprinted with permission from Chung et al. [10])

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Fig. 4
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Modified Mallampati Classification, classes I to IV. Mallampati classes: Class I corresponds to all structures visible (soft palate, uvula, fauces, and pillars); Class II, pillars are no more visible (soft palate, major part of uvula, and fauces visible); Class III, fauces are no more visible (soft palate and base of the uvula visible); finally, class IV, only the hard palate is visible. (Image courtesy from Dr. Maria Júlia Figueiró Reis. Original figure)

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The Narcolepsy Severity Scale is a measurement tool for quantitative evaluation of narcolepsy symptoms, useful for monitoring and optimizing the management of narcolepsy [13]. As a new assessment tool, it is only available in French [13, 25], Brazilian Portuguese [26], and Chinese [27].

The International Restless Legs Syndrome Rating Scale (IRLSRS) was developed by the International Restless Legs Syndrome Study Group to assess the severity of a patient’s RLS symptoms [14] (Fig. 5).

Fig. 5
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Restless legs syndrome rating scale for severity. (Reprinted with permission from Walters et al. [14])

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As we have presented in a separate chapter (chapter “Sleep and Chronic Pain Interlaced Influences: Guidance to Physiotherapy Practice”), there is a relationship between sleep and pain. Both can be evaluated together, by the Pain and Sleep Questionnaire Three-Item Index (PSQ-3), a direct measure of the impact of chronic pain on sleep [16]; and by the Chronic Pain Sleep Inventory (CPSI), a 5-item tool using a 100 mm visual analog scale [17]. A new measurement tool specifically designed and validated for the older ones is the Sleep Assessment Instrument for Older Person with Pain (SAIOAP) [18](Fig. 6).

Fig. 6
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Sleep assessment instrument for older person with pain. (Reprinted with permission from Santana et al. [18])

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To assess circadian preferences (i.e., whether a person’s circadian rhythm or biological clock produces peak alertness in the morning, in the evening, or in between) the Morningness Eveningness Questionnaire (MEQ) [19], which helps to determine individual differences in sleep-wake patterns, and the time-of-day people feel and perform best can be used (Fig. 7). Munich Chronotype Questionnaire (MCTQ) can assess individuals’ chronotypes – diurnal preferences that manifest in personal sleep-wake rhythms [20].

Fig. 7
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Morningness eveningness questionnaire. (Reprinted with permission from Terman et al. [28])

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The sleep diary is a record of an individual’s routine of sleeping and waking times. It can be fulfilled by the proper patient, by a caregiver, or by the parents. The sleep diary records the subjective perception of the sleep period (Fig. 8) and can be recorded for at least 10 days, in order to include weekdays and weekends, or more, depending on the case. Often patients record information such as the time the patient went to bed, the amount of time it took to fall asleep, time the patient left the bed in the morning, number of times patient awoke during the night, how refreshing overall sleep was, what may have disturbed patient’s sleep (breathing troubles, leg movements, insomnia, etc.), number and time of caffeinated and alcoholic beverages consumed throughout the day, medications taken during the day, time spent exercising and period of the day, activities performed prior to bed [29, 30]. The National Sleep Foundation has a good example of a sleep diary (www.sleepfoundation.org). Sleep diaries are typically used in addition to or in place of objective measures (i.e., polysomnography or actigraphy) and can be completed over multiple time points. It is a self-report measure in which patients and participants record their sleep patterns and answer other questions related to their sleep on a daily basis (e.g., sleep quality, daytime sleepiness, medication use). Sleep diaries capture night-to-night variability in sleep. It is a particularly important tool for assessing sleep routine for the physiotherapist and the patient, as they can have a better idea of the patient’s sleep patterns and habits, can help the physician with a diagnosis, and also can monitor the effectiveness of treatment. In addition, the sleep diary may help the patient to get more proactive about their sleep, knowing it better. Henceforth, we conclude best practice is to include both subjective and objective measures when examining sleep.

Fig. 8
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Consensus sleep diary with instructions. (Reprinted with permission from Carney et al. [30])

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FormalPara General Instructions

  • What is a Sleep Diary? A sleep diary is designed to gather information about your daily sleep pattern.

  • How often and when do I fill out the sleep diary? It is necessary for you to complete your sleep diary every day. If possible, the sleep diary should be completed within one hour of getting out of bed in the morning. The Nighttime Sleep Diary questions can be completed before you go to bed at night.

  • What should I do if I miss a day? If you forget to fill in the diary or are unable to finish it, leave the diary blank for that day.

  • What if something unusual affects my sleep or how I feel in the daytime? If your sleep or daytime functioning is affected by some unusual event (such as an illness, or an emergency), you may make brief notes on your diary.

  • What do the words “bed” and “day” mean in the diary? This diary can be used for people who are awake or asleep at unusual times. In the sleep diary, the word “day” is the time when you choose or are required to be awake. The term “bed” means the place where you usually sleep.

  • Will answering these questions about my sleep keep me awake? This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate.

FormalPara Morning Sleep Diary Item Instructions

Use the guide below to clarify what is being asked for each item of the Sleep Diary.

Date: Write the date of the morning you are filling out the diary.

  • 1. What time did you get into bed? Write the time that you got into bed. This may not be the time you began “trying” to fall asleep.

  • 2. What time did you try to go to sleep? Record the time that you began “trying” to fall asleep.

  • 3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep?

  • 4. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening?

  • 5. In total, how long did these awakenings last? What was the total time you were awake between the time you first fell asleep and your final awakening? For example, if you woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20 + 35 + 15 = 70 min or 1 hr. and 10 min).

  • 6a. What time was your final awakening? Record the last time you woke up in the morning.

  • 6b. After your final awakening, how long did you spend in bed trying to sleep? After the last time, you woke up

  • (Item #6a), how many minutes did you spend in bed trying to sleep? For example, if you woke up at 8 am but continued to try and sleep until 9 am, record 1 hour.

  • 6c. Did you wake up earlier than you planned? If you woke up or were awakened earlier than you planned, check yes. If you woke up at your planned time, check no.

  • 6d. If yes, how much earlier? If you answered “yes” to question 6c, write the number of minutes you woke up earlier than you had planned on waking up. For example, if you woke up 15 minutes before the alarm went off, record 15 minutes here.

  • 7. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g., you may have woken up at 6:35 a.m. but did not get out of bed to start your day until 7:20 a.m.)

  • 8. In total, how long did you sleep? This should just be your best estimate, based on when you went to bed and woke up, how long it took you to fall asleep, and how long you were awake. You do not need to calculate this by adding and subtracting; just give your best estimate.

  • 9. How would you rate the quality of your sleep? “Sleep Quality” is your sense of whether your sleep was good or poor.

  • 10. How restful or refreshed did you feel when you woke up for the day? This refers to how you felt after you were done sleeping for the night, during the first few minutes that you were awake.

FormalPara Nighttime Sleep Diary Item Instructions

Please complete the following items before you go to bed.

Date: Write the date of the evening you are filling out the diary.

  • 11a. How many times did you nap or doze? A nap is a time you decided to sleep during the day, whether in bed or not in bed. “Dozing” is a time you may have nodded off for a few minutes, without meaning to, such as while watching TV. Count all the times you napped or dozed at any time from when you first got out of bed in the morning until you got into bed again at night.

  • 11b. In total, how long did you nap or doze? Estimate the total amount of time you spent napping or dozing, in hours and minutes. For instance, if you napped twice, once for 30 minutes and once for 60 minutes, and dozed for 10 minutes, you would answer “1 hour 40 minutes.” If you did not nap or doze, write “N/A” (not applicable).

  • 12a. How many drinks containing alcohol did you have? Enter the number of alcoholic drinks you had where 1 drink is defined as one 12 oz. beer (can), 5 oz. wine, or 1.5 oz. liquor (one shot).

  • 12b. What time was your last drink? If you had an alcoholic drink yesterday, enter the time of day in hours and minutes of your last drink. If you did not have a drink, write “N/A” (not applicable).

  • 13a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? Enter the number of caffeinated drinks (coffee, tea, soda, energy drinks) you had where for coffee and tea, one drink = 6–8 oz.; while for caffeinated soda one drink = 12 oz.

  • 13b. What time was your last drink? If you had a caffeinated drink, enter the time of day in hours and minutes of your last drink. If you did not have a caffeinated drink, write “N/A” (not applicable).

  • 14. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken: List the medication name, how much and when you took EACH different medication you took tonight to help you sleep. Include medication available over the counter, prescription medications, and herbals (e.g., “Sleepwell 50 mg 11 pm”). If every night is the same, write “same” after the first day.

  • 15. Comments: If you have anything that you would like to say that is relevant to your sleep, feel free to write it here.